Gender and social protection and health policies promoted during the COVID-19 pandemic: Global scoping review and future challenges

Background Governmental interventions have been important tools for mitigating COVID-19 transmission, but they have also negatively impacted different gender-related components. We aimed to answer the following questions: What is the scope of the gender approach in the literature analysing health and social protection policies promoted during the COVID-19 pandemic? What are the challenges and recommendations for gender-sensitive policies for the post-pandemic and future crises? Methods The study design is based on three stages: a global synthesis of the evidence through a scoping review, the generation of a framework of emerging inequalities based on sociocultural markers, and the creation of a matrix with the challenges and recommendations. In this scoping review, we searched 10 online databases for studies published until April 2022 and conducted a content analysis on the extracted studies. Results Of the 771 identified records, 67 met our inclusion criteria. Most studies had a female person (52/67) as the first author. The binary model was the main approach addressed in the studies (61/67). The literature showed that the closure, distancing, and other social policies did not include a gender approach and generated negative gaps related to economic instability, reproductive roles, and gender violence. In the intersectionality dimension, multiple aspects emerged (macro, meso, micro-social level, and individual level). Greater gender gaps in connection with employment (related to increased housework) were observed during the closure and distancing stage of the pandemic. Asymmetries related to female participation in the management of the pandemic and an increase in discrimination and abuse of diversity groups were detected. Conclusions We observed gaps both in the gender approach both in knowledge and in policy implementation during the pandemic in the different countries explored in this work. This is a call to attention and action for researchers, political decision-makers, and other interested parties to incorporate and accentuate the gender perspective in all policies related to the post-pandemic period and future social and health crises.

We generated specific search strategies for each database based on combined terms in English, Spanish and Portuguese. Before developing the strategies, we carried out an exhaustive analysis of the dimensions and scope of this study, making it possible to generate sensitive strategies that we tested and refined to capture the greatest number of documents of interest (Appendix S1 in the Online Supplementary Document).
We also used the Google search engine to manually retrieve the references of both included and excluded articles captured by the initial search strategy, for which we conducted a full-text review. We eliminated duplicates found in the different databases.
We first evaluated the study titles and abstracts, after which we analysed the full text. If the full text of potentially a relevant scientific article could not be located, we tried to contact the author. Citations were managed with Endnote.
We prepared a register form to systematize the information of each document, which contained the pre-established dimensions and categories of analysis, with an open field to record emerging information.

Data extraction and analysis
We conducted a content analysis on the information gathered from the documents [18]. To improve internal validity and mitigate possible information bias, all the information collected was reviewed at least twice. Three independent reviewers (including DLM, MLM and LLM) assessed the included documents for relevance, detecting potential discrepancies and finally reaching a consensus on the final inclusion. We developed an emerging framework of socio-cultural markers and a matrix of challenges and recommendations.

Ethical considerations
The study was based on published documents. The manuscript was evaluated by the Institutional Health Research Ethics Committee (CIEIS) of the Hospital Nacional de Clínicas of the National University of Cordoba, Argentina (Number: PV-2022-00490734-UNC-CE#HNC).

Scope of gender in the literature
A total of 771 records were retrieved, 188 of which underwent a full text analysis. 208 records were screened through the additional manual search described above (Figure 1). A total of 67 articles were included (54 from the initial search strategy and screening and 13 from the citation screening (Figure 1)). Included articles written in other languages (Spanish = 3, German = 1, Vitimite = 1, Portugese = 5) were translated into English.
The included studies  either covered at least one country from the European region (n = 18), or countries from the Americas (n = 21, 13 from Latin America and 8 from North America), Africa (n = 10), Asia (n = 20), or Oceania (n = 4), while one had a global scope.
Fifty-four studies dealt with social distancing, restrictions, or lockdown policies, seven with employment, income, or social protection, and five with gender-based violence measures ( Table 1 and Figure 1). Most studies were conducted during 2020 (the first year of the pandemic caused by  and had a female first author (n = 52/67) ( Table 1).
Most studies approached gender through the binary model (61/67) with a predominantly male/female use of language, while some recognized that gender encompasses more than the binary and included other gender identities (eg, van Daalen et al. [23] and Cook et al. [26]).
These studies also recognized that the crisis is possibly affecting diverse gender identities [26] and that there is a need for intersectional data collection beyond a binary view [23] ( Table 1). We found a gender-diverse approach in only six papers whose analysis focused on people of different gender identities [36,49,56,61,67,70]. We also found studies that only superficially mentioned LGBTIQ+ groups [22,34,39,50,52,54,58,65].

Socio-cultural markers of emerging gender inequalities
Most studies highlighted the absence of a gender approach in the government policies promoted during the pandemic ( Table 1) by pointing out its implications on multiple socio-cultural markers related to gender inequalities ( Figure 2).  Response to COVID-19 from international, regional, and national governments National responses: focus on the infected, and border closures. Financial dependence, reduction of public spending on social services.

Viewpoint documentary analysis, interviews
Reflections on the responses to COVID-19 from international and regional organizations and national governments.
The national policy responses have been partial and inconsistent with respect to gender in Sub-Saharan Africa and Latin America without recognizing the multiple drivers of inequalities.

Qualitative approach
To study the impact of COVID-19 on unpaid work and gender differences in the urban centres in India.
Women were already sharing a higher burden of unpaid work, and COVID-19 and the lockdown has worked to increase their burden of unpaid work even more. Large numbers of decisionmakers turn to scientific experts to obtain information and to legitimize or justify decisions with the inclusion of scientific expertise.

Multi-stage document analysis
Examine the expert committee's advisers the governments, in disciplinary composition, gender representation and transparency.
In eleven committees, the members were known by name, women making up 26% of the members. The members of ten committees were not known.  In the pandemic, there was difficulty in obtaining food parcels or poor quality, and the slow payment of the Emergency Aid.

Qualitative approach
Discuss of the forms of violence experienced at the intersection of race, gender and class in a community of social vulnerability during the pandemic and before it.
During the pandemic and before it, to structural violence linked to race, class and gender, expressed in the inaccessibility to decent conditions of housing, food and basic income. Brazil has a context of public governance characterized by the neoliberal aegis, the denial of scientific evidence in political decision-making, the dissemination of false news.

Critical essay
To addresses the interconnection between social markers of the inequalities that affect marginalized groups as sex workers, domestic workers and the LGBTQIA+ community.
The pandemic has exacerbated the processes of stigmatization, marginalization and exclusion in certain groups that were already suffering from it.
Does not inform Female Inclusive Gender diverse

Intersectionality
Within the dimension of intersectionality, all studies have stressed or enunciated in their analysis at least some category at the macro, meso, and micro-social level (Figure 2 and Table 2) . From a micro-social sphere, markers related to mental health, sociodemographics, vulnerability conditions, food insecurity, loss and instability of employment, and loss of housing related to the pandemic, as well as policies taken by governments were observed. Employment and income policies had a central analysis in the works of Cook et al. [26], Foley et al. [37], Bariola et al. [38], Holder et al. [42], Fuller et al [72], Yaish et al. [77], and Hien et al. [78]. although in all the analysed studies, these markers were stated in some way during lockdown (eg, increased workload -formal, informal, domestic, and/or community work, loss or modality change of employment and income, feminized front-line employment and in other critical areas, sex workers in vulnerable situations, female-headed households, paid work and domestic work division, etc.) .
Cook et al. [26] showed how a short-time work scheme implemented in four European countries with different welfare regimes relied on a normative (male) worker without questioning the gender division of domestic work [26]. Another study carried out in Vietnam also highlighted the limitations of the development and implementation of protection policies to support ethnic minority groups where there has been no gender analysis [78].
Other aspects related to the loss of employment and income were observed, especially for Indian migrant women; their physical presence at the job site was crucial, as their jobs cannot be done online [40]. Moreover, it was observed that black women disproportionately lost jobs in United States [42].
A study in India found a greater loss of employment among women than among men during lockdown [46]. A qualitative study in India, carried out in a group of women from the informal labour sector during the lockdown, revealed how the multiple intersecting forms of inequalities create a complex "matrix of domination" including gender, caste, class, occupational, and religious identities [44].
A study in Bangladesh revealed critical factors related to women's continuing or closing down small businesses during the pandemic in a highly patriarchal context [62].
However, a study carried out in Canada from February to October 2020 showed that gender gaps which existed in employment in the parent group narrowed when restrictions were relaxed [72].
Other aspects at the meso-social level also emerged in the studies, such as reduction of access to services and infrastructure for protection and justice [30,32], or macro-social level markers, such as macroeconomic instability, reduction of public spending for social protection, and different problems on government data monitoring level. Omukuti et al. [21] indicate how financial dependency and austerity and reduced public spending on social services shaped COVID-19 responses in Latin American and Sub-Saharan African countries, showing the importance of recognizing macroeconomic factors as drivers of gender vulnerability in the COVID-19 pandemic.

Gender roles
Lockdown and social distancing policies were presented in the studies as strongly related to the dimension of social and cultural roles on reproductive and care tasks linked to women, which were widely present in most studies, though in different depth or scope, or just enunciated ( Table 1) .
Reproductive tasks were exacerbated and increased during the pandemic and by the government's lockdown measures. Additionally, during this period, a triple workload was generated: paid, domestic, and community work [35,47].
As Gordon-Bouvier postulated, there was a crisis of exhaustion and reduced resilience during the pandemic, particularly impacting those engaged in social reproduction, both inside and outside the home [73].
Moreover, a study in Australia found that the rise in "relative equity" during the lockdown did not compensate for the extra unpaid work burden the pandemic caused for women [41]. These measures also had negative impacts on the scholarly productivity in the group of female academics [24,60].
A study in Panama also delved into gender-segregated distancing policies, indicating lower visits to all community location categories on female-mobility days. As the authors claim, women could have undertaken fewer tasks outside the home than men [65].  Work on barriers to access to health services, social protection, childcare and justice (physical, geographic, language, cultural, perceived, resources and, among others) seeking an adaptation to the specific needs of groups. Improve working conditions, especially for women and other vulnerable groups. Consider paid family leave, for maternity and paternity, and female empowerment with an active role of the unions. Generate income equity policies that promote security, protection, decent wages, professional progression, and economic autonomy. Promote legislation on pay equity and the near-term, policies should continue financial and protection assistance, principally in vulnerable groups. Promote the expansion of protection programs such as nutrition and childcare, and increased unemployment insurance benefits, considering the particularities and indicators in specific groups. Generate labour policies and job creation programs that include informal and temporary workers (mainly feminized), addressing aspects of labour quality and training. Women and others who assume care roles will require flexible work schedules with the presence of care policies (such as childcare and early childhood services). The homeworking can generate financial costs (electricity, telephone, and office equipment), that should be considered from employers. Investments in highly feminized labour sectors, this will lead to the creation of more jobs. It is important to consider gender disparity in industries when designing employment policies, for example, promoting the role of women in traditionally male occupations. Rebuild the participation of women and other vulnerable groups in the labour force and promote labour equity policies, and prevention of discrimination in search of a reduction in the wage gap. Help the reintegration into work of women and other groups of diversity affected by the crisis. Universal access to food assistance programs must be a priority during the crisis. Review its proper functioning and generate work between different sectors. Developing loans policy by according the specific problems of women in small businesses, especially in highly patriarchal countries.

Mental health
Panic, anxiety, anger, stress, depression, uncertainty, stigma, discrimination, substance abuse, pre-existing mental health problems, grief, mental health may worsen in survivors of violence, suicides, fewer hours of sleep, mental health and services are stigmatized. Disability Difficulty with mobility and access to rehabilitation services.

Social protection and health, education
Feminization of poverty, loss of means of subsistence, housing problems and evictions, risk of sexually transmitted diseases and unwanted pregnancies, maternal and infant mortality, households headed by women, difficulty in accessing basic goods (hygiene, clothing, foods), low digital literacy, sexual education, access education, and autonomy in mobility, differences in levels of resilience.

Race, ethnic and religion minorities and migrants
Less access to employment, dependency on extended networks, inadequate care, illegal and legal migration, high concentration of refugee camps and shelters (with higher demand, spaces in poor condition), black women with disproportionately lost jobs, migrant or religion minorities job loss, social class and castes, colonial history, mass exodus of migrant workers.

Accessibility to services
Difficult geographic access (jobs, care services, courts), because of lack of public transportation, mobility restrictions and difficulty in access (interruptions and confinement) to social support, resources and essential health services (maternal and sexual health), childcare, justice services, care services for victims of violence, and medications (for example, antiretroviral or contraceptives).

Employment
Informality, sex work, precariousness, unemployment, exploitation, insufficient training, companies and jobs in the feminized sector were more affected, more women have lost their jobs (than men), lack of access to the employment support scheme, informal workers benefit disproportionately from protective measures, limited ability to work from home, layoff prevention package may have affected mothers (in a male breadwinner/female caregiver model), women out of the labour (withdrawal from free child care in the recessionary environment).

Income
Loss of income, wage gaps, weak financial safety nets, feminized low wages, economic dependency, limited savings, lack of coping strategies for economic survival, economic dependency and abuse, debt-default risks and imprisonment.
Self-perceptions Fear of attending health services, limited awareness of rights and protection laws, and stigmatized perception of well-being.

Nutrition and food security
Food shortages with rising prices, risk of malnutrition (due to micronutrient deficiencies and the presence of chronic diseases) and food insecurity due to cultural norms (women and girls sacrificing their food consumption for others in their family), situations of hunger in poor woman and in victims of violence, limited government food distribution scheme (during lockdown), with bureaucracy, lack of complementary measures (such as free transport), without establishing mechanisms to ensure that vulnerable families access food through different means (for example, NGOs), insufficient food baskets, or poor quality, closure of low-cost restaurants, affected food supply chains (with lack of incentives for subsistence farmers).

Dimension Socio-cultural markers Challenges Recommendations
Intersectionality Meso-social level Infrastructure, health services, social protection services, care services Reduction and interruptions of essential health services (sexual and reproductive health), childcare (closure of nurseries, schools, and kindergartens), and first response to violence (shelters closing for victims of violence and increased demand for shelter services), need for human resources trained in gender-based violence, limited access to connectivity, errors in public money transfer systems excluding vulnerable people or non-compliance or bad implementation, inefficiency in the operationalization of public policies, poor risk communication.
Promote essential and free remote assistance and support programs (via WhatsApp, email, app, platforms, and 24-h care) for victims of violence to facilitate access to essential services. Analyse the context of connectivity and digital literacy. Increase Internet and communication diapositive's (cell phones) access, including rural and remote areas. Promote access to health services (for example, sexual and reproductive health or trans people to gender transitioning services), social protection (especially in childcare) and to justice. Promote country guidelines to ensure the availability and access of a minimum package of essential services. Generate clear and transparent protocols for police action and first response services to violence. Provide economic support, direct transfers, unemployment insurance and housing assistance or refugee to survivors of violence. Generate comprehensive services and articulation between essential health, care, social protection and justice programs that take into account intersectionality and accessibility. Promote awareness campaigns and prevention of gender violence, through mass media (television, radio and social networks) with relevant materials from a cultural and local perspective. Generate access to information on protection measures for survivors of violence (as community centres, shelters, sites to report their situation of violence). Support activism, feminist movements, and initiatives of solidarity and mobilization so that governments respond to cases of gender violence. Support social and community organizations in the provision of violence services (although not a substitute for the government and the State). Promote the involvement of civil society in the design, implementation and evaluation of public policies and programs, promoting initiatives originating in the community. Promote gendersensitive justice and victim response systems with the generation of regulations. Train health, social protection and justice professionals from an intersectional approach. Develop co-interventions (for example, promote information on reporting violence in health centres, public centres, shopping malls, etc.). Generate transversal public initiatives in different areas of gender empowerment that promote parity. Review the performance of the money transfer systems and social protection.
Civil society Limited budget to provide services, lack of coordination between government and civil society, the State does not intervene and leaves the work on gender and violence to NGOs.

Legislation and access to justice
Laws that are not accessible (included language barriers), discriminatory and with unequal application, barriers to justice, courts, and local and religious counsellors (due to lack of public transportation, service interruptions), hostile judicial institutions not focused on survivors, police abuses, unfair informal and formal justice system, laws influenced by the patriarchal culture (including religion), long judicial processes with bureaucratic logistics, judicial personnel without technical knowledge on protection measures, cases of domestic violence that are not considered emergencies, binary laws that result in violence against a diverse gender. Macroeconomic instability, external dependence, recession, indebtedness, economic crisis, inflation of basic products (food), reallocation of funds, increasing levels of austerity, priority to debt service over investments in health, dependence on international financing to support policies of gender.
Assure and increase the financing of community organizations of gender violence with continuity in the provision of services. Generate an efficient allocation of resources in crisis and post-crisis. Promote coordination and federalism within the countries. Generate initiatives, alliances and dialogues between the State, communities, international institutions, civil society, activists, academia, professionals, and local officials. Promote a unified data surveillance and monitoring system with a gender approach from the different sectors (health, social protection, judicial and community), more data and research needed in the area. Work on a comprehensive and intersectional gender strategic action plan that includes not only immediate responses (first response services, childcare, unemployment insurance, economic aid, temporary housing, shelters, complaints, sexual and reproductive health services, food security), but also medium-and long-term responses based on access to stable resources and opportunities (education, employment, income, housing, institutions, structural and cultural changes). Foster recognition of care policies as an integral part of social, economic and employment policies. Generate knowledge from intersectionality and diversity with systematization of local experiences during the pandemic that serve as a starting point for the design of timely policies with a view to recovery. Assess the existing social security and care networks and policies, comprehensively, critically, deeply and detect any possible needs for improvement.

Public spending for protection
Cut downs on public spending, elimination of subsidies to basic goods, poorly financed gender institutions, support for "masculinized" industries and scarce support for "feminized" ones, lack of funds for childcare centres (or closure of existing ones), little support for care policies, cash transfer programs with values far below social needs.

Governance and public policies
Lack of coordination between different policies and fragmented institutions, ideology of the government in office, armed conflicts, little focus on intersectionality in policies (simplistic approaches), gender bias in state organizations, little transparency and low trust of public institutions, lack of health governance, controversies in political discourses, health approach in the emergency that excludes social considerations (such as gender), government scientific advisers without training in gender analysis, problems of implementation of policies and regulations, poorly financed gender ministries, ultra-neoliberal governments, extractive capitalism that exploits and destroys the environment, gender-segregated quarantines, environmental catastrophes.

Monitoring, evaluation, and data
Limited data on violence, lack of reliable, complete and scattered data, gender bias in data reporting, and data on gender violence managed by other community institutions are not captured.

Gender roles
Reproductive activities Exacerbated and additional domestic activities during confinement (household chores, caring for children, elderly and sick), masking of gender divisions in domestic work, mothers leaving the labour force (more than fathers), entrenched beliefs that women are responsible for care, marginalization of reproductive work, increased triple burden work during the crisis (job, domestic and community volunteering demands), interruptions of social connections, less support, lack or disruptions, or conditional eligibility in childcare services, restore of the traditional gender.
Establish care as a public policy problem. Guarantee the opening, operation and full access to the childcare system, kindergartens and schools. Provide additional and targeted support for families seeking to alleviate the increased burden of home care. Promote initiatives so that women can return to work "full time". Promote initiatives that generate more equality for unpaid activities in households. Generate educational campaigns appealing to the co-responsibility of care, and re-education of men who exercise gender violence and promote new masculinities that challenge the patriarchal culture.

Patriarchal cultures
Hegemonic masculinities, power asymmetries, patriarchal institutions and societies, social prejudices, during the crisis, the home emerges as a place of subordination, work and violence, women are less likely to make decisions in the crisis without autonomy over sexual and reproductive health. Predominance of the male gender in crisis management (for example, in expert committees) whit low transparency, gender stereotypes in institutional practices, leaders with the use of macho and warlike language, increasing the number of women does not necessarily lead to greater gender awareness in the decisions, prejudice against women, sexist institutional barriers, laws that reinforce the gender-binary, racism, discrimination.
Promote the participation of women and other genderdiverse groups in politics, crisis management and positions of power, considering the gender quota. Promote access to secure sources of information during the crisis. Promote committees sufficiently representative, interdisciplinary and intersectoral (including gender specialists and civil society), considering mechanisms of transparency in decision-making during the crisis and post-crisis. Promote the elimination of sexist institutional barriers by generating equality laws and measures to eliminate sexual and gender discrimination in public, institutional and power spaces. Generate efforts to address and reduce structural inequalities. Promote policies, programs and interventions based on intersectionality integral wellness with the involvement of society. Work on educational instances and awareness addressing gender stereotypes, sexist and macho culture, and promoting the empowerment of women and other groups of diversity. Guarantee compliance with, and access to, regulations on personal data and gender identity. Generate community networks for the approach, prevention and early detection of violence and gender inequalities at the territorial level. Generate the institutionalization of gender equality both at the macro level associated with formal rules and at the micro-level associated with individual perceptions and practices. Support feminist and diversity activism, promoting solidarity and social justice. Establish mental health support channels for diverse groups and generate and promote timely and specific actions. Promote accessing health services for LGBTIQ+ groups, within essential health services and prevention of the LGBTIQ+ phobia in the health institutions and other spaces.

Gender-based violence
Multiple violence's (physical, psychological, sexual, economic and social), structural violence, normalization of violence, workplace harassment, domination, sexual exploitation (with a lack of protection systems), women locked up in their homes with their abusers (increased risk of perpetration or intensification of the pre-existing risk with reduced opportunity to seek help), closure of schools leaving girls vulnerable to spending time with potential abusers, presence of problematic substance use, assault, and use of firearms, use of fear of contagion, and control of information such as mechanisms of abuse, increase in femicides carried out by men, prison permits for people for crimes of gender violence during the crisis, presence of double victimization (perpetration of violence and failures of protection systems), difficulties of survivors in accessing the complaint (with closure of public transport), entrenched culture that approves of violence as a means to control and subjugate women and culture of silence, human trafficking for prostitution, drug trafficking, police crackdown, child marriage and forced marriage.

Gender discrimination and violations of human rights
Gender-binary segregated restrictions, police brutality to enforce measures, abuses in quarantine centres, increased violence, margination, classism, racism, oppression, discrimination in crisis towards LGBTIQ+ community, sex workers, socially disenfranchised, ethnic minorities, sexual minorities refugees, migrants, or people with disabilities (even with the presence of more than one of these categories) are more likely to experience social problems (for example, food insecurity, violence, housing issues, job loss, lack of state protections or responses that exacerbate disparities), greater difficulty seeking and obtaining help, disclosure of personal data (problematic for some groups, difficulty in accessing protections stated in the gender identity law.

Asymmetries and inequalities
The implemented policies related to the dimension of asymmetries and inequalities; although they were stated in several texts, they took on a central role in studies specifically addressing gender-based violence (GBV) during the lockdown period (Table 1) [22,27,30,32,36,39,43,50,51,58,61,69,70,75,76] Difficulties in accessing essential services by survivors of GBV, both because they were unable to travel or seek help and because services were reduced during this period, were also reported in these studies [22,27,30,32,43,58,76].
Survivors of GBV with marginalized identities have been at greater risk of being doubly victimized by the perpetration of violence and by the failure of protection systems [22].
Dias Corrêa et al. [50] highlight that structural violence worsened during the pandemic lack of care by of the State.
Also, as indicated by Srivatsa [57], communication and outreach by local governments is critical. John et al. [43] showed how the Kenya government turned its attention to GBV only after reports of rising GBV led to advocacy by activist.
In this dimension, asymmetries related to the low presence of women in pandemic management committees or decision-making positions during the crisis were also visualized [23,25,29].
A study conducted in Canada and Scotland by Soremi et al. [35] indicated that female political leaders do not need to base their legitimacy on gender, even more so in environments where these policies have already been institutionalized, adding that the emphasis should be on professional progress.
In their global study, van Daalen et al. [23] showed how women's voices were excluded in expert working groups and decision-making during the pandemic, with very low gender parity. Furthermore, van Daalen et al. [23], Bacigalupe et al. (in Spain) [29], and Sell et al. (in Germany) [48] found a deficient level of transparency on the committees' composition.
Wenham et al. [25] found that, although the average number of women in scientific advisory groups on emergencies increased during the crisis, this did not imply a greater awareness of gender issues in politics. Similar ideas were expressed in other studies [20,23]. Kim et al. (in South Korea) [20] indicate that COVID-19 mitigation policies were sustained through a masculinized discourse related to policies focused on minimizing the spread of the virus and alienation from other social problems.
Perez-Brume et al. [36] clearly show the presence of violence and marginalization generated during the pandemic, pointing out serious and unacceptable situations suffered by transgender groups in some Latin American countries, such as Peru, Panamá, and Colombia, where the physical distancing policy was based on binary interpretations of gender.
The Irons' study analysing gender-segregated quarantine in Peru suggests that these events were more than just the results of the policy-makers' missteps, but rather the persistence and exacerbation of long-existing of colonial and patriarchal structures [52].
Rieger et al. [22] enunciated elements related to gender diversity, indicating that most survivors of gender-based violence are women and gender-diverse people. Different studies in Brazil, India, and Indonesia indicated psychological distress or mental health problems in gender-diverse persons during the pandemic, social distancing, and lockdown periods [49,61,67,70].
The pandemic's consequences for diversity groups are varied, with an increase in inequities and LGTBI-phobia presence [49]. Studies in Brazil and India [49,61,70] have shown that it exacerbated stigmatization and marginalization in already marginalized groups [61] such as gender-diverse persons.
However, Rodriguez Fernandez [34] and Polischuk et al. [39] provide examples of violence prevention services or social programs during the pandemic that included members of the LGBTIQ+ communities, as was the case of Argentina and New Zealand.
Also, the negative consequences of the closure were also observed in other groups such as sex workers, exposing them to exploitation by both their clients and the police [43]. It was also detected in India, where the patriarchal structure and social prejudices conditioned women's experiences of the COVID-19 crisis [44].
Studies have also pointed out the humiliation of migrant workers from India by state authorities during lock-down [45]. Dias Corrêa et al. [50] and Camilo et al. [51] also pointed out the structural violence from the police force in Brazil.
A study analysing the case of India indicated how the state and social mechanisms of power, following the pandemic outbreak, pushed the populations into precarious living situations and conferred upon them the status of "living-dead" [45].
Using the content analysis of the included documents ( Table 1)  and the emerging framework of socio-cultural markers (Figure 2), we developed a matrix to identify and adapt the main challenges and recommendations detected for consideration during the pandemic ( Table 2).
The COVID-19 pandemic has triggered unprecedented governmental and political action worldwide [88].
Strict health measures such as social distancing policies, isolation, and lockdown, have been implemented in many countries [89] and were the focus of many studies included in this review.
Although these measures are effective and imperative in curbing the spread of infectious diseases [89][90][91], they have also had negative effects on multiple spheres of wellness, and they are the subject of analysis due to their economic, social, and psychological repercussions [89][90][91][92].
The pandemic has amplified multiple existing inequalities [92], especially those related to gender as found in this study, but it also occurred at a time of demands for social change and greater equality with a growing feminist movement from before the onset of the COVID-19 pandemic [21]. However, the public health policies promoted during the crisis have not addressed the gendered impacts [2]; this has occurred in previous disease outbreaks [2,31,93] and was amply demonstrated in this study.
This omission of gender in health policies during the pandemic, in part, can be explained by the "tyranny of the urgent" [93,94], marked by a dissociation between immediate biomedical needs and those not considered a priority, such as inequities and structural problems.
This study also highlighted the methodological and scope limitations of studies published during this stage. A predominantly binary approach to gender has been observed, similar to what Williams et al. suggest [5].
Gaps were also evident at the level of the policies analysed and their impacts, as proposed by Agarwal [95].
The literature was largely focused on the immediate confinement measures and the consequences on care/ domestic work and violence [95], while there was no in-depth and central analysis of other inequity markers related to medium and long-term impacts that will surely affect recovery, such as food and nutritional insecurity, loss of livelihood, indebtedness, low resilience, and rising poverty [95]. Food and nutritional insecurity issues were considered by Chitando [31], Oladeinde [33], Arora et al. [40], Singh et al. [44], Bau et al. [55], and Pinchoff et al. [69] carried out in African countries and India. A part of the documents analysed the gender impacts globally and immediate employment consequences. The limitation in the scope of gender markers in the analysed studies was probably since most were conducted during the early stage of the pandemic, raising the need to generate new visionary and localized evidence.
Smith [93] postulated that, while health policy research may have incorporated gender analysis, few specific studies on gender issues are related to outbreaks. We found that gender gaps are still noticeable, as was reported in previous studies [93,95].
Another aspect to be highlighted was the presence of a smaller number of documents in some regions, such as Africa, despite the evidence of the COVID-19 pandemic's substantial impact and the partial and inconsistent policy response with respect to gender in this continent, as in Latin America [21]. Low-and middle-income countries show problems of gender inequity with fragile health systems; they should be more proactive in improving their evidence-based strategies to provide sustainable solutions and reduce the different gaps [96], requiring more studies in this territory.
Despite the limitations of the literature, a multiplicity of socio-cultural markers was found that translate into present and future gender-related challenges caused by the pandemic and the measures implemented by governments.
This study sought to address the policy measures generated during the crisis from an intersectional and located approach, not only considering individual conditions but a broader framework that recognizes the social and geopolitical forces that shape people's lives [97], assuming that communities are not homogeneous and that there is a diversity of experiences [45,97], and that the impacts of COVID-19 and the implemented policies will also be differential.
As we have observed, people with one or more identities (such as marginalized people, disability people, undocumented people, ethnic minorities, people of colour, sexual and gender minorities, migrant women, and cisgender women) may be particularly and disproportionately affected by the COVID-19 pandemic [22,97,98].
The gender-blind planning and decision-making in public health during the response to the COVID-19 pandemic stem from a hegemonic and patriarchal system, generating differential needs in these groups [98].
Besides the challenges mentioned above, there are other gender-blind spots, which also deserve attention, such as the low opportunities for female decision-making during the crisis [23,25,29,48]. However, the gender analytical lens found focused on the increased risk of gender violence, the domestic and reproductive work, and social inequalities, especially in employment and income .
This study's main strength is the comprehensive approach to the gender approach at both the policy and knowledge levels generated during the COVID-19 crisis.
Further research in this field will be necessary to reduce the current knowledge gap; to our knowledge, there are no published works similar to this study. The global evidence regarding the gender approach in public policies promoted during the COVID-19 pandemic in different countries and contexts until now has never been, to our knowledge, fully synthesized. Another strength lies in the potential of the emerging framework and policy recommendations generated from the data, which could serve, although duly adjusted and adapted, to post-pandemic contexts and future health, humanitarian, and environmental crises.
Limitations include those arising from the design itself and its descriptive and exploratory nature. However, the purpose of this work was not to systematically compare the studies, but rather to describe and comprehensively discuss the "state of the art" on the subject from a theoretical, methodological, and analytical point of view in order to generate policy recommendations and more specific future research.
Due to the nature of the study, we have not evaluated the quality of the evidence and there may have been information that was not captured and included by the search. For pragmatic and feasibility reasons, it was necessary to limit the search strategies in three languages (although the language was not an exclusion criterion) and during the initial screening stage, only one researcher reviewed the abstracts and titles. The review may have missed documents written in other languages.
However, we have made different efforts to achieve the revision of an important diversity of databases that allows us to capture the greatest possible number of experiences from different continents and countries.
A series of measures were taken to minimize inclusion biases: a researcher reviewed the titles and abstracts of all records and all full texts at least twice. A sample of studies excluded in the abstract and title review again underwent a full-text review, and three researchers independently reviewed the potentially included studies.
Publication bias could have existed, considering the emergency context (as much of the work was generated during the first months of the pandemic), making it less likely for studies with positive results or implementation of gender protection policies to be published. However, the focus of this work was based on inequities, although studies from countries where positive strategies were discussed.
Other limitations were the gender imputation of the first author through information collected from the web rather than from self-perception and that the historical, ideological, political, and normative differential context of each country with respect to gender advances was not considered. However, a certain consistency was found among the analysed studies regarding the approach and scope, which may indicate that, despite context-specific gender norms, the effects of the pandemic and the implemented policies could transcend geographical barriers, languages, social and cultural contexts, similar to those reported in a previous study [25].